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COVID19 Screening Questionnaire
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Are you in the 1a vaccination group?
*
Yes
No
Are you in the 1b or 1c vaccine group?
*
Yes
No
Address
*
Your answer
City
*
Your answer
State
*
PA
NJ
Zip Code
Your answer
Mobile phone number (123-456-7890)
Your answer
Race
*
Native Hawaiian or Other Pacific Islander
Asian
American Indian or Alaska Native
Black or African American
White
Other race
Unknown
Ethnicity
*
Not Hispanic or Latino
Hispanic or Latino
Unknown ethnicity
Fever of feeling ill today?
*
Yes
No
History of severe allergic reaction (e.g., anaphylaxis) to any component of this vaccine?
*
Yes
No
History of severe allergic reaction to another vaccine?
*
Yes
No
History of severe allergic reaction (e.g., anapylaxis) to an injectable therapy?
*
Yes
No
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
*
Yes
No
Have you received another vaccine in the last 14 days?
*
Yes
No
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
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